Background Information:

What are the other Names for the Procedure?

• Morphine Pump to Spinal Cord
• Pain Pump to Spinal Cord
• Spinal Pain Infusion Pump

What is the Intrathecal Morphine Pump surgical procedure?

• An Intrathecal Morphine Pump is used to deliver morphine into the subarachnoid space around the spinal cord directly. The subarachnoid space is the space around the spinal cord filled with cerebrospinal fluid
• The procedure helps in controlling pain symptoms with much lower doses of morphine
• The pump and morphine reservoir is placed under the skin of the belly and this is connected to a small tube (catheter) that ends in the subarachnoid space
• The pump can be programmed to deliver a specific dose of morphine at particular times, and the reservoir can be refilled by injecting morphine into it through a needle inserted via the skin

What part of the Body does the Procedure involve?

Intrathecal Morphine Pump procedure involves the vertebrae, subarachnoid space around the spinal cord, and superficial layers of tissue of the abdomen.

Why is the Intrathecal Morphine Pump surgical procedure Performed?

Intrathecal Morphine Pump procedure is performed to provide relief from long-standing or chronic pain symptoms as in:

• Pain due to cancer
• Pain due to nerve injury
• Persistent back pain or leg pain not responding to conservative and/or surgical treatment
• Reflex sympathetic dystrophy

What are some Alternative Choices for the Procedure?

Medication to control pain, physical therapy, steroid injections, and alternative kinds of therapy, such as acupuncture, may be used to relieve pain in some cases. Surgery may also be indicated in some instances. The healthcare provider may help in finding alternative choices for the condition.

What are the Recent Advances in the Procedure?

There are no recent advances in this procedure.

What is the Cost of performing the Intrathecal Morphine Pump surgical procedure?

The cost of Intrathecal Morphine Pump procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused by the information regarding the Intrathecal Morphine Pump technique and on what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist and also recommend another physician, if required
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.medcentral.org/main/SpinalInfusionPump.aspx (accessed on 05/20/2015)

http://www.mayfieldclinic.com/PE-PUMP.htm#.VH5zjGdgrtA (accessed on 05/20/2015)

Prior to Intrathecal Morphine Pump surgical procedure:

How is the Intrathecal Morphine Pump surgical procedure Performed?

• The Intrathecal Morphine Pump procedure maybe performed under general anesthesia.
• The individual is turned to his/her side and the surgeon makes an incision on the middle of the lower back to expose the vertebral bone
• A small tube (catheter) is placed such that the tip lies in the subarachnoid space
• This tube is the extended to the front of the belly by using an extension catheter. This lies under the skin throughout
• The surgeon then makes a small incision on the skin of the lower belly to place the pump
• The extension catheter is connected to the pump
• The skin incisions are sutured

Where is the Procedure Performed?

An Intrathecal Morphine Pump procedure is performed in a hospital.

Who Performs the Procedure?

The Intrathecal Morphine Pump procedure is performed by any of these medical personnel, with or without assistance from an anesthesiologist:

• A neurosurgeon

How long will the Procedure take?

The Intrathecal Morphine Pump procedure may take 1-2 hours to perform.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the Intrathecal Morphine Pump procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are currently being taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time before the procedure is performed
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products for a while before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For individuals suffering from diabetes, it is important that the blood sugar stays within the normal range; if not, their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Intrathecal Morphine Pump procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Intrathecal Morphine Pump surgical procedure?

Before an Intrathecal Morphine Pump, the patient has to undergo certain tests such as:

• Trial injections of morphine are given to find out if it helps with controlling pain
• Chest x-ray
• EKG
• Routine blood and urine analysis

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is an Intrathecal Morphine Pump technique?
• Why is this procedure necessary? How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed?
• What are the risks while performing the procedure?
• What are the complications that might take place during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required after the procedure?
• What are the costs involved?

During the Intrathecal Morphine Pump surgical procedure:

What kind of Anesthesia is given, during the Procedure?

General anesthesia by injection and inhalation is administered during the procedure.

How much Blood will you lose, during the Procedure?

Negligible blood loss during an uncomplicated Intrathecal Morphine Pump procedure may be expected.

What are the possible Risks and Complications during the Intrathecal Morphine Pump surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally, the greater the degree of obesity, the greater the surgical risk
• Smoking: The longer the smoking history (in pack years smoked), the greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders and chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during the Intrathecal Morphine Pump surgery are:

• Excessive bleeding
• Infection within the surgical wound
• Anesthetic complications

What Post-Operative Care is needed at the Healthcare Facility after the Intrathecal Morphine Pump surgical procedure?

• After the DBS for Pain procedure, the patients are sent to an area of the hospital called the postoperative recovery area (or PACU)
• The patient’s blood pressure, heart rate, and respiration cycle shall be closely monitored. Any additional pain associated with the procedure will be treated
• Individuals are usually discharged from the hospital on the same day as the procedure if there are no complications

After the Intrathecal Morphine Pump surgical procedure:

What are the possible Risks and Complications after the Intrathecal Morphine Pump surgical procedure?

The possible risks and complications that may arise after an Intrathecal Morphine Pump procedure are:

• Excessive bleeding
• Infection within surgical wound
• Catheter blockage
• Leakage of cerebrospinal fluid

What is the Prognosis after the Surgery?

The prognosis depends on the severity of the condition. Vast majority of patients have improved symptoms after an Intrathecal Morphine Pump procedure.

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

• Worsening pain and swelling around the surgical wound
• Bleeding or fluid drainage from the surgical wound
• The occurrence of any symptom that causes uneasiness such as nausea, vomiting, abdominal swelling, or constipation
• Signs of an infection
• Headache, muscle aches
• Dizziness
• Fever, feeling sick
• Complications associated with prescription medications used in treatment

What Post-Operative Care is needed at Home after the Intrathecal Morphine Pump surgical procedure?

At home, the following post-operative care is recommended after an Intrathecal Morphine Pump procedure:

• Slowly resume regular/daily activities as early as possible
• Resume showering after surgery, but keep the wound clean and dry. Avoid taking baths until the surgical wound is completely healed. Gently wash the surgical wound with mild or unscented soap
• Replace the dressings on the surgical wound after showering
• Avoid lifting heavy weight, sleeping on the belly, raising arms above the head, and excessive stair climbing for up to 2 months after the procedure
• Avoid driving for two to four weeks, or until permitted by the physician
• Complete the course of prescribed medication under advice of the physician
• Take antibiotic medication to help combat or prevent infection, per your physician’s advice
• Avoid taking nonprescription medications such as aspirin
• Take note of instructions from the healthcare provider regarding making adjustments on the stimulator

How long does it normally take to fully recover, from the Procedure?

Recovery from the procedure may take a few weeks.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The Intrathecal Morphine Pump procedure does not involve the surgical removal of any tissue.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is removed during the procedure, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Intrathecal Morphine Pump surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• A hospital
• An anesthesiologist
• A neurosurgeon

The patient is advised to inquire and confirm the type of billing, before the Intrathecal Morphine Pump procedure is performed

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA